GRADY HARRIS iHuman CASE STUDY “TUMMY ACHE” LATEST UPDATES MAY 2023. QUESTION CORRECT, Exams of Nursing

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GRADY HARRIS iHuman

CASE STUDY “TUMMY

ACHE” LATEST

UPDATES MAY 2023.

QUESTION CORRECT ANSWERS

AS PER THE MARKING

SCHEME LATEST PREVIEW

MAY 2023

Physical Assessment - Yields 94% Respiratory Rate 50, normal, unlabored Blood Pressure on one arm 68/40, normal, hypotensive Brachial pulse on both arms 160, normal rhythm, weak Cognitive Verbal Inspect skin overall (^) Skin cool, sweaty, andslightly mottled. Thoracotomy scar consistent withhistory of AV-septal repair. Diffuse diaper rash. Faint circumferential macular discolorations at wrists consistent with aging ligature marks. Capillary refill (fingers) Less than 3 seconds Capillary refill (toes) 4 seconds Quinke’s Test Blanching observed

Visually inspect abdomen (^) Ecchymosis overlying the epigastric measuring 10 cmin longest diameterand oval in shape, abdomen distended, 2 cm umbilical hernia. Auscultate lungs Normal in all fields bilaterally Auscultate heart Murmur, early systolic. Palpate for PMI PMI nondisplaced. Palpate abdomen (^) Abdomen distended, firm. Diffuse tenderness to palpation with associated guarding and rebound. Reducible umbilical hernia. Visually inspect extremities No overt limb deformities or bony crepitus. Moves all extremities spontaneously but weakly; no evident focal deficits. Faint circumferentialmacular discolorations at wrists consistent with aging ligature marks. GUmale exam (^) Atraumatic, diffuse diaper rash, normal circumcisedmale, testesdescended; nontender, no evidence of inguinal herniation. Inspect for muscle/bulk tone normal bulk, no rigidity, no signs of trauma. Inspect/palpate back/spine Nontender tovertebral palpation, no overt back deformities. Palpate extremities No localized musculoskeletal pain topalpation of extremities. Look in ears with otoscope Tympanic membranes intact, no hemotympanum, no signs of otitis media. Look for involuntary movements None of the following involuntary movements: fibrillations, fasciculations, asterixis, tics, myoclonus, dystonia’s, chorea, athetosis, hemiballismus, nor seizures. MSAP - Not graded Abdominal pain following a minor fall MSAP Poor appetite Related One episode of vomiting Related Lethargy Related Sweating Related

Tachypneic Related Decreased urination, dark, strong-smelling urine Related Listless, ill appearing Related Decreased responsiveness Related Tachycardia Related Hypotension Related Abdominal distention; epigastric bruising Related Diffuse abdominal tenderness, guarding, rebound tenderness Related Atrial-Septal-Defect s/psurgical repair Unknown Dental Caries Related Down Syndrome, global developmental delay Unknown Lowincome, single parent w/multiple young children Unknown Small for age, Down Syndrome features Unknown 3/6 systolic murmur Unknown Reducible 2.0 cmumbilical hernia Unknown Fading (old) ligature marks Unknown Diaper Rash Unknown History of CHF Resolved Problem Statement Grady is a 26-month-old male w/Down Syndrome brought in by mother who reports that he has been “whining” about abdominal pain x2 days, one episode of vomiting, he is lethargic, sweating, breathing rapidly, and has decreasedurine output that is dark in color. Mother reports symptoms began after Grady “fell out of bed during his nap” while under the care of her boyfriend. She denies any knowledge of head trauma but reports that he is not eating or drinking. Denies prior injuries requiring medical attention. PMH significant for s/p ASD repair w/transient CHF in infancy. Child appears listless and pale. Differential Diagnosis - Yields 100% Diagnosis Lead Alt MNM Blunt Abdominal Trauma X X Child Abuse (Acts of Commission)

X X

2. Child abuse - act of commission Electronic Health Record Reason for encounter (^) Grady is here today brought in by his mother with reports of "not being himself", he is whining and refusing to eat, and she thinks that he is trying to say that his tummy hurts. History of present illness (^) Two-day history of decreased appetite and thirst with abdominal pain, one episode of vomiting, decreased urinary output withdark, strong- smelling urine noted indiapers. Mother reports that he has been low in energy and withdrawn, sweaty/clammy following a "fall frombed while napping" while under the care of her boyfriend. General Complaints of listlessness, fatigue, lethargy, decreased energy, denies fever. HEENT/Neck Mother denies throat pain, hoarse voice, and foul-smelling breath. Denies sinus problems, dysphagia, nose bleeds, nasal discharge, or dental disease. Denies ear pain, hearing loss, ringing in ears, discharge. Denies use of corrective lenses, redness, blurring, or visual changes of any kind. Cardiovascular (^) Mother reports history of ASD with repair, transient CHF in infancy. Denies chest pain, palpitations, orthopnea, edema, peripheral cyanosis. Respiratory Mother isreporting more rapid breathing. Denies other respiratory complaints. Gastrointestinal (^) Mother reports complaints of abdominal pain, one episode of vomiting. Mother denies diarrhea, constipations, red or tarry black stools. She reports that she has not changed a stool diaper recently. Genitourinary Mother reports decreased urinary output and dark, strong-smelling urine in diapers. Musculoskeletal/Osteopat hic Structural Examination Mother denies back pain, joint swelling, stiffness, or pain, fracture history. Neurologic (^) Mother reports developmentally delayed due to Down Syndrome. Poor verbal communication. Denies syncope, seizures, black out spells. Mother reports that the patient is "clumsy" and "doesnot look where he's going", so he bumps into things a lot - implying unsteady gait. Integumentary/Breast (^) Mother reports bruising to the patient's stomach, cool, clammy skin. Denies rashes, bleeding, or any lesions/moles. Reports occasional diaper rash.
3. Systemic inflammatory response syndrome (SIRS)

Psychiatric Mother reports increased fussiness over the last 2 days. Denies sleeping difficulties. Endocrine (^) Mother denies night sweats, increased thirst, swollen lymph nodes, palpable masses, increased hunger, cold or heat intolerance. Hematologic/Lymphatic (^) Mother reports that the patient bruises easily but denies blood disorders or abnormal bleeding. Allergic/Immunologic Mother denies known environmental or medication allergies. PMH (^) Normal pregnancy, uncomplicated birth. Atrial Septal Defect, Transient CHF, Heart Murmur Hospitalizations & Surgeries Atrial septal defect repair. Preventative health Mother reports patient is up to date on all vaccinations except for his "most recentones". Medications No current prescription or over the counter medications. Allergies No known diagnosed allergies Social History (^) Lives with mother and two other siblings, one of 6-months, the other 5 - years old. Mother has boyfriend who occasionally watches the children while she works. She is a single mother - but dating the father of her 6 - month-old child. Patients father is not in the picture. Mother is a cashier at a local retailer, only graduated high school, cannot afford daycare. She relies heavily on her boyfriend and her neighbors to help watch her children so she can work. She denies use of alcohol and other illicit drugs. Family History Mother: anemia Father: unknown 5 - year-old sibling: asthma 6 - month-old sibling: healthy Physical Exam General (^) Lying on exam table, listless, sucking thumb, noted increased respiratory rate, responsive to verbal stimuli, delayed responses. HEENT/Neck Head: no signs of head trauma, Down Syndrome facies: flat face, upslanting eyes. Scalp: no visible scaliness, edema, masses, lumps, deformities, scars rashes, nevi, or other lesions noted, non-tender to palpation. Eyes: no conjunctival pallor, sclerae anicteric. PERRLA bilaterally. Ears: normal appearing external structures, no deformities or edema, no discharge noted. Tympanic membranes intact, no hemotympanum, no signs of otitis media. Nose: no discharge or polyps, noedema or tenderness over the frontal or maxillary sinuses. Mouth: no hoarseness, oropharynx not injected, clear mucosa, tonsils without exudate, tongue is normal color, symmetrical, no swelling or ulcerations, normal gag reflex. Dental caries noted. Neck: no visible scars, deformities, or other lesions. Trachea is midline and freely mobile. No asymmetry or accessory muscles used with quiet breathing. Thyroid is firm

What historical or physical findings would lead you to suspect a nonaccidental, or intentional, injury in a child? Poor dentition, injury/injuries inconsistent with reported injury, rib fractures on chest x-ray in multiple Choose all that apply. stages of healing. Select the option that best describes Munchausen’s syndrome The syndrome is related to Munchausen by proxy, a form of child abuse. Which of the following are the first and second most lethal injuries seen in physical child abuse? C. Head injuries B. Abdominal injuries Management Plan ● Initial resuscitation and stabilization: ● Assess airway, breathing and circulation. ● Place on continuous cardiac monitor and continuous pulse oximeter to monitor VS ● Provide oxygen supplementation for hypoxia. ● Establish twolarge bore intravenous line: Administer IVisotonic-fluid bolusesasneeded. ● Complete primary (airway, breathing, circulation, disability, exposure) and secondary ● (head totoe exam) surveys. ► After the primary survey, the student should recognize that this is a critically ill child. Evaluation: ● Obtain a SAMPLE history: Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading up to the injury or illness. ● Order additional diagnostic testing, including labs and imaging, as needed. ● Obtain an emergent surgical consult. ● Admit the patient to the ICUfor further management. ● Mobilize security personnel, if indicated. ● Contact child protective services: contact police and social-work personnel, asneeded. ● Tommy will be admitted to the pediatric intensive care unit. The hospital as local police and child protective services were notified. The patient’s currently being interviewed by the police and the social worker will provide reliable contact information for her boyfriend. Updates The mother’s boyfriend (Drew B.) wasinterviewed by the police. He admitted he could not take the whining,” and “punched Tommy in the stomach and threw himon the bed the boyfriend was arrested and is awaiting trial. Tommy had a prolonged ICU stay, but progressively improved to the point of readiness. Social services and child protective servicesassisted the obtaining additional financial support forday care, counseling, and mandated classes. Tommy and his two siblings are in the custody of child protective receiving counseling. Jackie J. currently has supervised visitation.